PrimeCuts: This Week in the Journals

April 13, 2009

eggPhilip Formica MD

Faculty Peer Reviewed

It is Easter weekend, and as children enjoy themselves on easter egg hunts, I await to feast with my family. However, in the meantime I find myself reviewing the various articles throughout the week.

Once again, the importance of exercise is shown in patients with chronic heart failure. In JAMA this week, the HF-ACTION trial randomized 2331 medically stable outpatients with heart failure to usual care or usual care plus aerobic exercise training. These patients had a LVEF of <35% or less and NYHA class II-III despite optimal treatment for at least 6 weeks. Main outcome measures included primary end points of all-cause mortality or hospitalization and secondary end points of all-cause mortality, cardiovascular mortality or cardiovascular hospitalization, and cardiovascular mortality or heart failure hospitalization. Exercise training demonstrated a nonsignificant reduction in primary and important secondary end points. After adjustment for highly prognostic predictors of the primary end point, exercise training was associated with modest significant reductions for both all-cause mortality or hospitalization and cardiovascular mortality or heart failure hospitalization.

Obesity is a major concern in the US and brown adipose tissue may prove to be an important factor. In rodents and newborns, brown adipose tissue is involved in energy expenditure. However, the role of brown adipose tissue in adults is unknown. A study from the NEJM analyzed 1972 patients with PET-CT scans done for various diagnostic reasons. Positive scans, defined as the detection of brown adipose tissue, were identified in 76 of 1013 women (7.5%) and 30 of 959 men (3.1%) [P=<0.001]. Interestingly, the amount of brown adipose tissue was inversely correlated with body-mass index, especially in older people, suggesting a potential role of brown adipose tissue.

 Another article from the NEJM randomly assigned patients with inadequately controlled asthma and with minimal or no symptoms of gastroesophageal reflux to receive either 40 mg of esomeprazole twice a day or matching placebo. The results showed that treatment with a PPI did not improve asthma control. The authors concluded that asymptomatic gastroesophageal reflux is not a likely cause of poorly controlled asthma.

A NY Times article shows the potential of Botox. The toxin has been used to eradicate wrinkles for several years. However, several physicians throughout the country have been using the “miracle” toxin for other indications including chewing problems, swallowing problems, pelvic muscle spasms, drooling, hair loss, anal fissures and pain from missing limbs. Since some of these indications are off label use, there is concern for severe life-threatening complications. As the market for Botox continues to broaden, the FDA continues to review its safety and keep up with the expanding market.

Another article demonstrates the positive impacts of an electronic medical system. Approximately 42 percent of active family doctors have installed some type of electronic health records, according to estimates by the American Academy of Family Physicians. The benefits mentioned include less medical errors and time efficiency. However, start-up costs can reach $30,000-$50,000. A promising prospect on the horizon is the $20 billion section of the $787 billion economic stimulus package that will be invested in information technology for health care, which may help physicians in the initial costs.

Reviewed by Joshua Remick MD, Section Editor, Clinical Correlations

1. O’Connor CM, Whellan DJ, Lee KL, et al. Efficacy and Safety of Exercise Training in Patients With Chronic Heart Failure. JAMA 2009; 301: 1439-50.

2. Cypess AM, Lehman S, Williams G, et al. Identification and Importance of Brown Adipose Tissue in Adult Humans. NEJM 2009; 360: 1509-17.

3. The American Lung Association Asthma Clinical Research Centers. Efficacy of Esomeprazole for Treatment of Poorly Controlled Asthma. NEJM 2009; 360: 1487-99.

4. Singer, N. So Botox Isn’t Just Skin Deep. April 11, 2009; NY Times, BU1.

5. Freudenheim, M. As Medical Charts Go Electronic, Rural Doctor Sees Healthy Change. April 10, 2009; NY Times, B3.

Philip Formica is a third year resident in internal medicine at NYU Medical Center.